Industry Group Calls for
Opioid Restraint in MSAs

By: Nancy Grover
Friday, May 6, 2016

The National Alliance of Medicare Set-Aside Professionals is calling for limits on the duration and doses of opioids.

Medicare set-asides are the latest battleground for the effort to stem opioid abuse. A nonprofit organization that helps companies with the process for adhering to the Medicare Secondary Payer statute is calling on a government agency to set limits on the duration and doses of the drugs.

Despite research showing the ineffectiveness and risks of opioids for most injured workers, the Centers for Medicare and Medicaid Services continue to seek large payments for opioids in MSAs. The National Alliance of Medicare Set-Aside Professionals is asking CMS to instead use evidence-based guidelines in considering the costs for opioids included in MSAs.

“CMS’ own opioid overutilization policy recommends Part D sponsors lower their safety edits to set red flags for beneficiaries taking a 120 mg morphine equivalent daily dose for more than 90 days and with prescriptions from more than three prescribers/pharmacies,” NAMSAP said in a statement.

“So why do workers’ compensation MSA approvals often include future prescription allocations with Morphine Equivalent Dosages in excess of 120, 200, or even 500 per day, over the beneficiary’s full life expectancy? And what message does a workers’ compensation MSA supporting these high opioid dosages over a patient’s entire life expectancy send to the addicted patient?”

“Why do workers’ compensation MSA approvals often include future prescription allocations with Morphine Equivalent Dosages in excess of 120, 200, or even 500 per day, over the beneficiary’s full life expectancy?” — statement from the National Alliance of Medicare Set-Aside Professionals.

The organization is asking CMS to limit projected costs of opioids in MSAs by using a hard cap of 90 MED based on CDC guidelines for no more than one month when the MSA includes a surgical projection and/or a hard cap of 40 MED for no more than one month followed by a 10 percent per week mandatory tapering and weaning plan, as recommended by the CDC, until fully weaned from opioids.

The request comes on the heels of the Centers for Disease Control and Prevention’s recently released opioid guidelines.

“With all the attention [on opioids], you have the Medicare set-aside and you have the requirements from CMS in terms of preparing that set-aside that require you to take current medical and pharmacy treatment and project the cost of that over the life expectancy of the beneficiary,” said Rita M. Wilson, a NAMSAP board member and CEO of Florida-based Tower MSA Partners.

“In a real-world example of a person taking 20 mg of Oxycontin three times per day, what CMS will expect you to do is to project the cost of 20 mg of Oxycontin over the life expectancy of the beneficiary. So if the person is 50 and will live to 82, that’s 32 years. While on one hand it’s a dollar value, on the other hand it absolutely violates every treatment guideline we know of.”

Counterproductive Care

NAMSAP cites various studies showing that long-term use of opioid medications for chronic, non-cancer pain is “ineffective, counterproductive and, if left unchecked, deadly.” It says the risk of disability at one year doubles for patients using opioids for more than seven days, and many of those prescribed opioids for more than three months will still be on the drugs in five years.

Opioids are not intended for long-term use, they are not intended to manage chronic pain. They are for acute pain and intended for the short term,” Wilson said. “We’re saying, in a real-world situation, in practice, you’d never allocate for these, you’d never allow this to continue for 20 or 30 years; yet CMS is basically doing that.”

NAMSAP suggests MSA vendors and CMS work together to address the opioid epidemic. “While we recognize the ultimate goal is to come up with a dollar value that adequately considers Medicare’s claim, the treatment that is being applied to create that number is treatment that is in conflict with its own guidelines.”

Nancy Grover is the president of NMG Consulting and the Editor of Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at riskletters@lrp.com.